Thoughts on Ophtho future outlook?

[sheek111]

Hey guys!

Saw this article: version: http://webcache.googleusercontent.com/search?q=cache:2r_WbvNVpScJ:www.medscape.com/viewarticle/768302 &cd=1&hl=en&ct=clnk&gl=us

And this:
http://www.abstractsonline.com/plan...bc3&mKey=6f224a2d-af6a-4533-8bbb-6a8d7b26edb3

Hard to predict the future, but curious as to what effects all of these upcoming ACA changes might have on Ophthalmology? Both job market wise and with Medicare moving away from a fee-for-service payment model to value-based care? I'm not up to date on all of this, and was just curious about what these changes might do in the long-term. Esp considering what others have said about ophtho job market being overly saturated already with semi-low 140k ish salaries in mid-sized cities. (just through doing forum search). Would cuts mean less potential to add new partners because of 40-50% overhead already required? And since Ophtho is primarily focused on elderly pts (most of medicare!) Will all these changes/cuts hurt us as new grads in the coming years more than other specialties? I still think Ophtho is an amazing field and am still interested. Just curious about what this means. If the future of Ophtho is still as lucrative as it was in the past. Thoughts?

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[LightBox]

Please see my responses here:

http://forums.studentdoctor.net/threads/ophthalmologist-salary.1044953/#post-16226988

 

[sheek111]

Thanks! I saw these posts and was curious:

http://forums.studentdoctor.net/threads/can-you-believe-ophtho-starting-salaries.514307/

http://forums.studentdoctor.net/threads/ophtho-vacancies-recently.928504/#post-12739896

http://forums.studentdoctor.net/thr...logy-jobs-in-california.900816/#post-12334173

Salary just seems super variable. Like some ppl making <100k and others that own practices or have been in the field forever making much more. So I guess the average gets skewed. But of course it's always a bad decision to pick a specialty for compensation. Esp given the current state of medicine, and specialists getting cut/markets saturated with midlevels and optoms. Ophtho is still a cool field regardless of what happens in the coming years as we start looking for jobs. Thanks for the response!

 

[LightBox]

Sure, if you are desperate, you can accept those 90k associate jobs. Most people who take those jobs are: (1) Geographically bound to an area (e.g. spouse's job or family or "I just can't imagine living anywhere else but Malibu"); or (2) have a 2nd source of income through their spouse, so they don't have to worry about being the breadwinner for their family.

Again, there is a HUGE variation in compensations out there for Ophthalmologists. From those crappy 90k associate jobs in the Bay Area...to the 250k starting salaries at Kaiser (but which max out at 350-400k)... to the 2-3M compensation that some of the practice-owners make around here. The difference is usually based on how much competition there is, and how business-minded you are. Obviously, it is unlikely you will make 7 figures without being a business owner since a lot of one's profit is derived from the difference between the revenue an associate/optometrist brings in, and how much you pay them. And of course, other revenue streams like ASC ownership, optical, hearing aids, leasing out space in your office building, etc.

Those salary surveys are generally very inaccurate and I highly doubt that your local eye surgeon who is doing 60 cataracts and 60 LASIK a week, is filling out those surveys.

 

[sheek111]

Thanks Lightbox. I appreciate you providing me with that insight! Recently in clinic, my mentor just enlightened me and his other trainees on all of these concerns he has about the future of Ophthalmology as a whole...more so because of the impending ACA reform/SGR repeal denials/reimbursement cuts. With medicare continually taking a hit, it makes sense that Ophtho might be hit much harder than other specialties, given the pt population. He works in a large group practice, and honestly probably isn't so much concerned about himself because he's close to retiring, but he talked about hindsight. Like things he's heard about at academy meetings etc. He should probably write a book, and is definitely VERY business minded, as you mentioned above. But he said that the future medicare reimbursement issues in combo with the immense overhead (40-50% overhead seems ridiculous compared to every other specialty)/business costs in Ophtho specifically, will ultimately lead to the death of private practice altogether. Like that Ophthalmologists will most likely be headed towards more working like a hospital employee would in the near future. I'm assuming similar to hospitalists? But his take on all this from aao meetings and such, was that this will likely lead to huge decreases in salary/compensation because specialists are getting hit much harder. And that Ophtho's whole potential to generate larger salaries than other specialists is hugely because of the private practice aspect, which will prob disappear soon. So with all that said, I was wondering what that meant for graduates like 3-5 years from now. Either way, I still think the field is awesome. And I'm not being swayed by income/future lifestyle. But at the same time, it's important to be aware of these issues while deciding on next steps (academics/fellowship vs. private practice). Also, agreed on the surveys! I think like 2% of the population fills those out. So definitely not a good estimate

 

[Andrew_Doan]

Still hard to predict, but there will always be a need for ophthalmologists. It's whether we work for ourselves in private practice vs being employed by "someone else".

I chose to be employed by the US Navy and moonlight in a private practice in Temecula (a practice I built with a few others from the ground up). Seeing the headaches of insurance reimbursements and declining reimbursements in private practice, I am so thankful I have a Navy job!

While moonlighting, for instance, the local ER doc calls me for a corneal foreign body removal at 2 AM. I asked for the patient's insurance info: the ER doc, says "it's a commercial insurance..." I spend an hour with the patient only to discover the patient's insurance is an HMO assigned to an IPA group (basically controlled by a primary care group). I am not hopeful of being paid for services rendered or my office manager spends a lot of time trying to get reimbursement (burning time, resources, and money); so, the cost of doing business is increasing while reimbursements are decreasing.

It's also harder to get reimbursements from some insurances due to "red tape", so we have accounts receivables that extend to nearly 6 months!!! Imagine doing a cataract surgery last September, and you're still waiting for reimbursement because of denial of claims and resubmissions! I don't mind charity work, but I need to pay the lease, loans, employees, malpractice insurance, and overhead. I am the last to be paid unfortunately, if there's anything left over.

 

[Slide]

Thanks Lightbox. I appreciate you providing me with that insight! Recently in clinic, my mentor just enlightened me and his other trainees on all of these concerns he has about the future of Ophthalmology as a whole...more so because of the impending ACA reform/SGR repeal denials/reimbursement cuts. With medicare continually taking a hit, it makes sense that Ophtho might be hit much harder than other specialties, given the pt population. He works in a large group practice, and honestly probably isn't so much concerned about himself because he's close to retiring, but he talked about hindsight. Like things he's heard about at academy meetings etc. He should probably write a book, and is definitely VERY business minded, as you mentioned above. But he said that the future medicare reimbursement issues in combo with the immense overhead/business costs in Ophtho specifically, will ultimately lead to the death of private practice altogether. Like that Ophthalmologists will most likely be headed towards more working like a hospital employee would in the near future. I'm assuming similar to hospitalists? But his take on all this from aao meetings and such, was that this will likely lead to huge decreases in salary/compensation because specialists are getting hit much harder. And that Ophtho's whole potential to generate larger salaries than other specialists is hugely because of the private practice aspect, which will prob disappear soon. So with all that said, I was wondering what that meant for graduates like 3-5 years from now. Either way, I still think the field is awesome. And I'm not being swayed by income/future lifestyle. But at the same time, it's important to be aware of these issues while deciding on next steps (academics/fellowship vs. private practice). Also, agreed on the surveys! I think like 2% of the population fills those out. So definitely not a good estimate

It sounds cliche, but would you rather work in a field you didn't like simply for more pay, or be paid less but enjoy what you do thoroughly? Pay cuts are always looming on the horizon for many specialties but it's not anything new. I'd rather do this then work as a hospitalist or an ER physician while earning more. It is true that practices are consolidating but it's still possible to do private practice. My co-residents are going straight into private practice after residency and the future looks great for them so far. It helps that they will be able to do procedures that are cash-only.

Specialists are probably going to take a hit; vitrectomies have just taken a hit in reimbursement and I have a feeling intravitreal injections are going to be scrutinized much closer in the future. I'm not surprised that the reimbursements have gone down either because the newer vitrectomy technologies allow for faster surgery. Some of my mentors are predicting that the salaries of employed and/or academic physicians may start to narrow the gap with private practice ophthalmologists, either in a good or bad way. It's just hard to predict until the changes are at the doorstep.

 

[ophthope]

It may be rocky, but if taken to the extreme end where Medicare reimbursement becomes unsustainably low I can imagine many physicians both generalists and specialists will just stop accepting it. When that happens if people have to choose between cash-only cataract surgery or some other convenience item, I'm sure many will choose to see better over a car payment or a new living room set. Ultimately we provide an incredibly valuable service to patients and hopefully we will remain able to make an appropriate income for the vast training and work we bring to patient care. By the time all of the pre-op and post-op care are done, the patient is likely paying us less per hour than their estate lawyer. Sort of an absurd world already.

If doctors like Dr. Doan are taking hospital call just for the hope that they can bill patients seen on call - I think the reality of the world these days is that you're providing charity care. Dr. Doan is awesome and probably just sees that as part of his ministry, but I've gotten the advice to never take call for a hospital unless you're paid to do it because there is absolutely no way that the patients you will see there will be billing very well. Let the hospital either pay you what you're worth or transfer the patient to another hospital who is paying an Ophthalmologist for their services. I'd be glad to hear others' opinions on call reimbursement structures.

 

[Slide]

It may be rocky, but if taken to the extreme end where Medicare reimbursement becomes unsustainably low I can imagine many physicians both generalists and specialists will just stop accepting it. When that happens if people have to choose between cash-only cataract surgery or some other convenience item, I'm sure many will choose to see better over a car payment or a new living room set. Ultimately we provide an incredibly valuable service to patients and hopefully we will remain able to make an appropriate income for the vast training and work we bring to patient care. By the time all of the pre-op and post-op care are done, the patient is likely paying us less per hour than their estate lawyer. Sort of an absurd world already.

If doctors like Dr. Doan are taking hospital call just for the hope that they can bill patients seen on call - I think the reality of the world these days is that you're providing charity care. Dr. Doan is awesome and probably just sees that as part of his ministry, but I've gotten the advice to never take call for a hospital unless you're paid to do it because there is absolutely no way that the patients you will see there will be billing very well. Let the hospital either pay you what you're worth or transfer the patient to another hospital who is paying an Ophthalmologist for their services. I'd be glad to hear others' opinions on call reimbursement structures.

General consensus, at least from what I've heard in the South, is that hospital call will net you very little, if any, reliable patients to your practice compared to the time and effort put in. The advice you've heard seems to be pretty universal across the country.

 

[eye love lamp]

It may be rocky, but if taken to the extreme end where Medicare reimbursement becomes unsustainably low I can imagine many physicians both generalists and specialists will just stop accepting it. When that happens if people have to choose between cash-only cataract surgery or some other convenience item, I'm sure many will choose to see better over a car payment or a new living room set. Ultimately we provide an incredibly valuable service to patients and hopefully we will remain able to make an appropriate income for the vast training and work we bring to patient care. By the time all of the pre-op and post-op care are done, the patient is likely paying us less per hour than their estate lawyer. Sort of an absurd world already.

If doctors like Dr. Doan are taking hospital call just for the hope that they can bill patients seen on call - I think the reality of the world these days is that you're providing charity care. Dr. Doan is awesome and probably just sees that as part of his ministry, but I've gotten the advice to never take call for a hospital unless you're paid to do it because there is absolutely no way that the patients you will see there will be billing very well. Let the hospital either pay you what you're worth or transfer the patient to another hospital who is paying an Ophthalmologist for their services. I'd be glad to hear others' opinions on call reimbursement structures.

From someone who works at a hospital that is dumped on constantly from ophthalmologists at surrounding hospitals - can confirm. It seems even those who do get paid to take call for the hospital still refuse to see the patients and just ship them out without even evaluating them first.

 

[DrZeke]

From someone who works at a hospital that is dumped on constantly from ophthalmologists at surrounding hospitals - can confirm. It seems even those who do get paid to take call for the hospital still refuse to see the patients and just ship them out without even evaluating them first.

I am still in residency but this seems true in my neck of the woods as well. We are regularly dumped on by private ophthalmologists taking call at surrounding hospitals. They will refuse to operate on patients without insurance. They will usually say they can't perform a globe exploration or orbit exploration because they aren't qualified... We've also seen EMTALA violations or people taking care of someone for a few visits in office and once They realize they need a surgery or something else they dump it on the local residency program....

I don't mind the cases coming to us but it makes me wonder about what happens to people when they get out into practice and about the ethics surrounding these situations.

 

[LightBox]

I am still in residency but this seems true in my neck of the woods as well. We are regularly dumped on by private ophthalmologists taking call at surrounding hospitals. They will refuse to operate on patients without insurance. They will usually say they can't perform a globe exploration or orbit exploration because they aren't qualified... We've also seen EMTALA violations or people taking care of someone for a few visits in office and once They realize they need a surgery or something else they dump it on the local residency program....

I don't mind the cases coming to us but it makes me wonder about what happens to people when they get out into practice and about the ethics surrounding these situations.

Just wait until you are in private practice trying to see these uninsured patients. There is no incentive to see them. Even if you give your time away for free to these patients, oftentimes it is better for the patient to be seen at a residency program or academic center where they can, for example, obtain eye medications for free. Or at least plug in with a social worker to get "into the system." Another issue is increased liability because of poor patient follow-up or compliance. Oftentimes, these patients will just fall off the face-of-the-earth for a few weeks, and then finally come back with their condition severely worse. And guess who they are blaming? Definitely not themselves.

An example is a uninsured patient with a sight-threatening corneal ulcer. Even though I can easily manage this patient, I can't do much if the patient can't afford fortified antibiotics which he will be on for an extended period of time. And no, my practice isn't going to be buying his month-long course of eye meds for him. And no, the compounding pharmacy is not going to mix this stuff up before getting paid first. For this patient, it is better for him to get seen at a residency program or academic hospital so that perhaps he can get his medications mixed up.

Here's a deal I will propose to the U.S. government: if they pay the loans for all of my equipment, then I will agree to see a certain % of un-/under-insured patients! Otherwise, I would rather not to go bankrupt.

 

[RestoreSight]

Haha. So private practice docs essentially function as profit filters. The ethics of this argument are up for debate. Medicaid pays for fortified antibiotics and at least at my residency (large urban center, medicaid population), I don't think we ever give fortifieds out "for free." Ironically, there is substantially less liability in this patient population because they lack resources that the urban middle class possess, plus you will never be held liable for a K ulcer that runs wild after a patient misses his follow up appointments or doesn't fill his prescriptions. In addition, although this certainly happens, it is not endemic to less well insured populations and also is a problem with private patients as well. I have never seen a medicaid or uninsured patient with a serious eye condition "blame" his doctor for it. They are usually in pain, in distress and seeking help. Really the real reason these patients aren't seen in private offices comes down to money. They take time, they pay poorly, they require frequent visits, and they are no fun, but the irony is they need the most help and being turned away may cause unnecessary delays in their diagnosis and treatment and that's where the ethics get murky. There is more to being an ophthalmologist than cataract, lasik, and lucentis..

 

[eye love lamp]

I am still in residency but this seems true in my neck of the woods as well. We are regularly dumped on by private ophthalmologists taking call at surrounding hospitals. They will refuse to operate on patients without insurance. They will usually say they can't perform a globe exploration or orbit exploration because they aren't qualified... We've also seen EMTALA violations or people taking care of someone for a few visits in office and once They realize they need a surgery or something else they dump it on the local residency program....

I don't mind the cases coming to us but it makes me wonder about what happens to people when they get out into practice and about the ethics surrounding these situations.

We are in the same boat, and by the sounds of it maybe the same area.

My favorite 3 patients from the last 3 months:

1. 70 year old uninsured female with acute angle closure with CRAO in one eye. Private ophtho tells her that she needs to pay $1000 per eye for a laser that "will prevent you from going blind." Turned out to be an LPI. Patient paid, had procedure in both eyes. One month later private ophtho tells her she needs further laser (PRP) and will need to pay $2,500 per eye. Patient says she can't pay this, and thus she got kicked to us.

2. 50 year old male (with insurance) with PDR (presumably) s/p PRP. He is referred to resident clinic from a comprehensive ophthalmologist for consideration of cataract extraction. The outside group told him that we "were the experts in cataract removal and he should come to us" He had 20/400 vision and it turned out that they shot PRP right through the macula. They were thinking that after we did the CE that he would blame his unrecovered vision on us.

3. Cornea specialist (who offers PKP) refers his personal patient (with good insurance) to resident clinic for a 3 mm central corneal laceration because it's "outside of his scope of specialty." I guess his scope becomes limited on Friday afternoons.

It's ok to not treat patients to avoid your practice going broke. But I have dozens of examples were private practice folk go above and beyond the unethical boundaries.

 

[TheLesPaul]

Or the:

1. Patient with terrible PDR and 1+ NS OU; sent from large private cataract/LASIK mill s/p CE/IOL OU for "diabetes management". Of course, the patient paid cash for the surgery.
2. Patient s/p CE/IOL at outside private cataract mill, sent on Friday afternoon with endophthalmitis. I guess they don't have collegial relationships with the retina guys who catch their dropped lenses?
3. Numerous patients who pay cash ($1-2K) for LPIs for POAG with 0.95 cup, then sent to us for further management.

Some nasty people out there.

 

[Slide]

The above cases really do irk me when they show up on call or at the last minute on a Friday afternoon. As a senior, I am getting more exposed to what it takes to run a successful clinical practice, and I understand that there's the finances to worry about. Obviously it doesn't make sense to have nonpaying or significant number of Medicaid patients. However, in both these patients and in private patients, I've seen dumps that made me seriously question the intentions of referring physicians. The ones I can remember off the top of my head...

1) 68 yo male with NS OU, has what seems to be a 20/200 cataract OD despite the cataract appearing more like a 20/80-100 cataract, until I learned the patient had Ambylopia in that eye with previous LASIK.

2) private pt from another ophthalmologist referred to us for optic neuritis. Pt has had a well documented history of episodes in the past, and has classic symptoms. Though the other pt had treated the patient in the past, he for some reason wants us to take care of her.....on the weekend. The best part is that when that patient was discharged, the same physician was asking us not to transfer her other eye care to is. Classic.

3) It's just not ophthalmologists, it's also optometrists too; during resident clinic, a 6 year old kid was referred to is for a VEP due to "blindness"; either the kid's blindness took care of itself magically or the optom had no clue how to refract a kid, because it was the easiest 20/20 refraction that day.

Some of it is money, but some of it is also lifestyle; on a Friday afternoon, when you have plans for the weekend, the temptation is there to boot and refer away a possible train wreck.

 

[DrZeke]

These are similar to some of our cases. Also, we have patients that are refused care at other hospitals where ophthalmologists are PAID to cover these hospitals. But if it involves a procedure they can pretend they "can't manage"... They don't want to do it. They come up with reasons...

And yes it's always on a Friday afternoon or on a weekend. Also, we have had patients with insurance - good insurance - that have come with RD the afternoon of a holiday. Seen by a doc who was willing to see him, but wasn't a retina specialists because literally all retina specialists in town refused to even assess him, so he sent the pt to our residency program. Retina has a different lifestyle than other sub specialities or at least it is supposed to. Nobody wants to have to work on a holiday night but one of my attendings has always said "treat every patient the way you would want your own mother treated". Money is money, I get it. But then don't agree to take call somewhere.

 

[LightBox]

Obviously, there are going to be a few bad seeds out there. There is also a lot of selection bias, since residents/fellows are rarely seeing patients from private docs who don't punt their patients to the local academic center. Trust me, even us private eye docs see the "punts" from other practices that don't know or don't want to manage something like AACG/NVG or a corneal ulcer on the Wednesday before Thanksgiving. I personally have sent maybe one patient to the prominent academic center ~1 hour away during the past 3 years. And only because I do not own the piece of equipment (i.e. dCPC) that was most appropriate for this patient's problem.

I'm sure all of you have a co-resident or two that are lazier than others with their clinical care. I bet you many of these lazy residents will eventually become lazy attendings that don't want to deal with a serious medical issue on a Friday late afternoon. As a resident, I would also caution you from ever bashing an outside referring doctor, especially to the patient. The ophtho world is very small, and it probably won't help your job or fellowship prospects if you are known as someone that is self-righteous and criticizes the "all-evil" private practice doc. Trust me, there is laziness, sloth, and fraudulent care everywhere -- even in the hallowed ivory tower of academic centers.

 

[DrZeke]

I'm sure all of you have a co-resident or two that are lazier than others with their clinical care. I bet you many of these lazy residents will eventually become lazy attendings that don't want to deal with a serious medical issue on a Friday late afternoon. As a resident, I would also caution you from ever bashing an outside referring doctor, especially to the patient. The ophtho world is very small, and it probably won't help your job or fellowship prospects if you are known as someone that is self-righteous and criticizes the "all-evil" private practice doc. Trust me, there is laziness, sloth, and fraudulent care everywhere -- even in the hallowed ivory tower of academic centers.

I know the issues are not so black and white. You are right we are seeing things from a certain point because we don't get to see the big picture. There are all types in all walks of life and all professions. You made some excellent points.

 

[eye love lamp]

These are similar to some of our cases. Also, we have patients that are refused care at other hospitals where ophthalmologists are PAID to cover these hospitals. But if it involves a procedure they can pretend they "can't manage"... They don't want to do it. They come up with reasons...

And yes it's always on a Friday afternoon or on a weekend. Also, we have had patients with insurance - good insurance - that have come with RD the afternoon of a holiday. Seen by a doc who was willing to see him, but wasn't a retina specialists because literally all retina specialists in town refused to even assess him, so he sent the pt to our residency program. Retina has a different lifestyle than other sub specialities or at least it is supposed to. Nobody wants to have to work on a holiday night but one of my attendings has always said "treat every patient the way you would want your own mother treated". Money is money, I get it. But then don't agree to take call somewhere.

So maybe the private practice can have a pass for the Friday afternoon gig. If you only have operating privileges at an Amb Surg Center it may be hard to repair a minor trauma.

I just can't fathom why or how these physicians can charge insurance-less patients more money for a procedure than the reimbursement rate than private insurance. You're getting paid cash and can't cut them a discount for being able to avoid the headaches of the insurance company?

 

[ophthope]

So maybe the private practice can have a pass for the Friday afternoon gig. If you only have operating privileges at an Amb Surg Center it may be hard to repair a minor trauma.

I just can't fathom why or how these physicians can charge insurance-less patients more money for a procedure than the reimbursement rate than private insurance. You're getting paid cash and can't cut them a discount for being able to avoid the headaches of the insurance company?

1. I agree with the top part there. I hate all of the Friday afternoon transfers too, but honestly I bet a lot of comprehensive and even some retina doctors quite frankly don't have an operating room to go to after 4:00PM Friday. The ASC isn't going to bring in it's staff on the weekend for you to repair an open globe, and often the local hospital OR doesn't have the tools to do that surgery. I don't fault them too much for that. I do fault them for telling the ER to transfer a patient for a canalicular laceration without ever even coming in to look at the patient. You can't diagnose a canalicular lac on the phone, and if you can't put in a silicone tube anymore then at least make sure it's canalicular involving before I come in at 3:00AM for something the ER doc at the hospital you transferred from could have sutured up or you could have sutured since you're getting paid to be on call.

2. You misunderstand how price negotiation with insurance companies often works. You have to say "I charge $1,000 for an LPI" and then the insurance company says "I'll pay you $300" and you say okay. If the insurance companies finds evidence that you in fact charge uninsured patients $300 for an LPI, they will renegotiate the price to $50. In legaleze the $1,000 charge is your 'usual fee' and Medicare agrees to pay you a certain percentage of your usual fee. Charging an uninsured patient less than that when you are telling Medicare that you charge $1,000 is actually Medicare fraud. Functionally, charging more to the uninsured is the only way that you actually get paid anything reasonable by Medicare and private insurers. The system is broken and has been since we let insurers dictate what we charge patients.

Medicaid pays for fortified antibiotics and at least at my residency (large urban center, medicaid population), I don't think we ever give fortifieds out "for free." Ironically, there is substantially less liability in this patient population because they lack resources that the urban middle class possess, plus you will never be held liable for a K ulcer that runs wild after a patient misses his follow up appointments or doesn't fill his prescriptions.

1. I'm sure you give them out for free. Yes, Medicaid pays for them. But they don't pay for uninsured patients to have them. And if you're not *already* on Medicaid, they don't go back and pay you for services rendered prior to the patient getting on Medicaid.

2. "Never being held liable" does not equal "never getting sued." Doesn't matter if you did everything appropriately, you're still going to miss multiple days of clinic and have an insane amount of stress over a suit like that. Lawyers know you need to work to make a living as a Doctor and any lawyer will wait until the trial date, ask for delays, do anything to get you to miss more days and disrupt your workflow to make you more likely to settle out of court. I'm a resident now and like that I don't have to worry about this, but in private practice an uninsured, squirrelly patient is going straight to the nearest ivory tower to be managed.

 

[MstaKing10]

Haha. So private practice docs essentially function as profit filters. The ethics of this argument are up for debate. Medicaid pays for fortified antibiotics and at least at my residency (large urban center, medicaid population), I don't think we ever give fortifieds out "for free." Ironically, there is substantially less liability in this patient population because they lack resources that the urban middle class possess, plus you will never be held liable for a K ulcer that runs wild after a patient misses his follow up appointments or doesn't fill his prescriptions. In addition, although this certainly happens, it is not endemic to less well insured populations and also is a problem with private patients as well. I have never seen a medicaid or uninsured patient with a serious eye condition "blame" his doctor for it. They are usually in pain, in distress and seeking help. Really the real reason these patients aren't seen in private offices comes down to money. They take time, they pay poorly, they require frequent visits, and they are no fun, but the irony is they need the most help and being turned away may cause unnecessary delays in their diagnosis and treatment and that's where the ethics get murky. There is more to being an ophthalmologist than cataract, lasik, and lucentis..

Medicine as a business didn't become real to me until I was the one that had to cover my overhead, pay for my techs and employees wages and benefits, pay for the lease to my office and responsible for the purchase and maintenance of my equipment. It was further hammered home when I became responsible for covering my gigantic malpractice insurance premiums, and paying for my meetings, CME and license renewals. The "murkiness" you speak of often times boils down to "can I keep my doors open." I think the greed and laziness, which I can't deny does exist in some cases, is really the exception not the rule. Being in an academic center really skews your view because you deal with these handful of docs who seem to abuse the system. You don't get as easily exposed to the hundreds who do a great job for their patients.

To clarify a few points: I oftentimes give fortified antibiotics for free (we make them right in our office), they are expensive and we cover the loss for our uninsured patients. In cases of emergencies where I'm not on the patientes insurance plan, I will still hand out the antibiotics. Medicaid and unfunded patients are likely the MOST litigious of patients, don't fool yourself into thinking they are not. I have seen PLENTY of patients blame their doctor for something that was clearly not the physicians fault. Finally, not all doctors in private practice (as you imply) are the lazy, greedy, selfish, money hoarders that you believe. There are plenty of fantastic and ethical doctors that provide excellent care for all types of patients. The healthcare system is far more complex than you seem to understand and oftentimes hinders the ability of these fine physicians to practice in the way they would like.

 

[Slide]

Medicine as a business didn't become real to me until I was the one that had to cover my overhead, pay for my techs and employees wages and benefits, pay for the lease to my office and responsible for the purchase and maintenance of my equipment. It was further hammered home when I became responsible for covering my gigantic malpractice insurance premiums, and paying for my meetings, CME and license renewals. The "murkiness" you speak of often times boils down to "can I keep my doors open." I think the greed and laziness, which I can't deny does exist in some cases, is really the exception not the rule. Being in an academic center really skews your view because you deal with these handful of docs who seem to abuse the system. You don't get as easily exposed to the hundreds who do a great job for their patients.

To clarify a few points: I oftentimes give fortified antibiotics for free (we make them right in our office), they are expensive and we cover the loss for our uninsured patients. In cases of emergencies where I'm not on the patientes insurance plan, I will still hand out the antibiotics. Medicaid and unfunded patients are likely the MOST litigious of patients, don't fool yourself into thinking they are not. I have seen PLENTY of patients blame their doctor for something that was clearly not the physicians fault. Finally, not all doctors in private practice (as you imply) are the lazy, greedy, selfish, money hoarders that you believe. There are plenty of fantastic and ethical doctors that provide excellent care for all types of patients. The healthcare system is far more complex than you seem to understand and oftentimes hinders the ability of these fine physicians to practice in the way they would like.

That is a great point, the most litigious patients I've dealt with have been Medicaid/uninsured patients. Unfortunately some of the worst patients are in that demographic and can ruin your mood for days. And definitely most private practice ophthalmologists are awesome, it's always the few bad ones that ruin your day (or weekend). The way I see it, their examples are what you should strive to avoid after residency.

 

[TheLesPaul]

That is a great point, the most litigious patients I've dealt with have been Medicaid/uninsured patients. Unfortunately some of the worst patients are in that demographic and can ruin your mood for days. And definitely most private practice ophthalmologists are awesome, it's always the few bad ones that ruin your day (or weekend). The way I see it, their examples are what you should strive to avoid after residency.

Of course, you're right. We just like to complain because our Friday night is ruined .

 

[eye love lamp]

2. You misunderstand how price negotiation with insurance companies often works. You have to say "I charge $1,000 for an LPI" and then the insurance company says "I'll pay you $300" and you say okay. If the insurance companies finds evidence that you in fact charge uninsured patients $300 for an LPI, they will renegotiate the price to $50. In legaleze the $1,000 charge is your 'usual fee' and Medicare agrees to pay you a certain percentage of your usual fee. Charging an uninsured patient less than that when you are telling Medicare that you charge $1,000 is actually Medicare fraud. Functionally, charging more to the uninsured is the only way that you actually get paid anything reasonable by Medicare and private insurers. The system is broken and has been since we let insurers dictate what we charge patients.

I don't think it's as cut and dry as this.

http://www.gpo.gov/fdsys/pkg/FR-2003-09-15/pdf/03-23351.pdf This federal register had a small section proposed that you be allowed to perform procedures cheaper/for free for indigent populations. The whole thing got overturned, but this language exists out there.

https://www.healthlawyers.org/Events/Programs/Materials/Documents/MM13/d_ruskin.pdf
VII A 3, on page 10, states "Substantial discounting to the uninsured, including the non-indigent, does not render a hospital's charge structure entirely fictitious."

This is an old physicians practice article: http://www.physicianspractice.com/articles/who-cares-what-you-charge-you-should
"Have a uniform fee schedule for all physicians, if possible, and at least by specialty. Avoid charging different fees to different patients; you can, however, allow a reduction in the payment for self-pay patients. I often see groups offering a 30 percent discount to patients who do not use an insurance company and make their payments at the time of service (thereby encouraging prompt payment instead of a lengthy collections battle)."


Some of the people I work with in private practice do this. A local retina person charges uninsured patients $100 for a complete visit. OCT/FA included. $150 if he thinks the patient needs Avastin. He's never had an issue with the insurance companies or Medicare over this.

 

[LightBox]

I don't think it's as cut and dry as this.

http://www.gpo.gov/fdsys/pkg/FR-2003-09-15/pdf/03-23351.pdf This federal register had a small section proposed that you be allowed to perform procedures cheaper/for free for indigent populations. The whole thing got overturned, but this language exists out there.

https://www.healthlawyers.org/Events/Programs/Materials/Documents/MM13/d_ruskin.pdf
VII A 3, on page 10, states "Substantial discounting to the uninsured, including the non-indigent, does not render a hospital's charge structure entirely fictitious."

This is an old physicians practice article: http://www.physicianspractice.com/articles/who-cares-what-you-charge-you-should
"Have a uniform fee schedule for all physicians, if possible, and at least by specialty. Avoid charging different fees to different patients; you can, however, allow a reduction in the payment for self-pay patients. I often see groups offering a 30 percent discount to patients who do not use an insurance company and make their payments at the time of service (thereby encouraging prompt payment instead of a lengthy collections battle)."


Some of the people I work with in private practice do this. A local retina person charges uninsured patients $100 for a complete visit. OCT/FA included. $150 if he thinks the patient needs Avastin. He's never had an issue with the insurance companies or Medicare over this.

Ok, please save your last post for when you are out in the real world in a few years. We will expect you to see every uninsured patient at a severely-discounted rate (or for free). That should make your employer very happy

 

[MullerCell]

Another difficulty in private practice can be the patient's ability to pay for surgery. I see any and all uninsured patients that are referred to me, regardless of ability to pay. I can lower their price and let them set up some type of payment plan for my fees (which very rarely ends up being paid), but I can't control the hospital or surgery center charges. They want money upfront no matter what, even for something emergent. If the patient truly can't come up with the money, they can't have surgery. In this rare instance, I've done a pneumatic in the office (for free) on a less than ideal candidate and it has worked, but your hands are kind of tied and I can see why someone would just not accept a patient or transfer care if there is a nearby academic center.

I have never been involved in a law suit, but I really don't think people are inclined to be litigious if you treat them with respect, take good care of them, and they feel like you honestly care.

I could go on and on about the Friday afternoon dumps I get in private practice from other ophthalmologists and optometrists. I think people tend to just dump in the path of least resistance. They call anything an RD and send it to you just to get it out of their office. Most of the time it isn't an RD, and often isn't even a retinal condition.

 

[eye love lamp]

Ok, please save your last post for when you are out in the real world in a few years. We will expect you to see every uninsured patient at a severely-discounted rate (or for free). That should make your employer very happy

I don't know where you misunderstood that I expected private practice physicians to see all uninsured for free/extreme discount. My strong belief is that if you encounter a poor, uninsured patient with an acute condition, you should either:
a. Refer them to an academic center or to a low-cost provider
b. Offer them what they need (eg LPI) at a reasonable, discounted rate (such as what your reimbursement from Medicare is)

What one shouldn't do is
c. Tell them "This laser will prevent you from going blind." and charging them $1000 per eye.

My last post above replying to your "To not charge them $1000 is Medicare fraud" was simply saying I don't think this is necessarily fact. If I get into private practice and start thinking indigent patients are simply big cash cows that get me more money than my Medicare and private insurance patients that will be when I quit medicine.

 

[Eyefixer]

Mullercell, you state you have never been through a lawsuit. Neither have I (knock on wood). But I know colleagues that have. If one has never been through one, it's hard to imagine how devastating this can be emotionally, financially, as well as having effects of future employment opportunities. In my experience, similar to others on this forum, uninsured and underinsured patients are the most acute, mismanaged, high risk patients as well as most litigious. As much as I would love to help everyone that comes through my door, I generally pass on high risk problems at this point with regards to these patients. It's not worth the assumed liability.

 

[ophthope]

What one shouldn't do is
c. Tell them "This laser will prevent you from going blind." and charging them $1000 per eye.

You have to be very, very careful with trusting what patients tell you another doctor said. I've literally been standing in the back of a room while an attending spoke with a patient during intern year, came back to re-round later in the day on the same patient only to have that patient tell me that "the head doctor this morning told me..." and have them relay a completely different message than what I witnessed being told.

I've also seen follow ups from other residents and have a good chuckle when I tell my co-resident what the patient said their last doctor told them. Here for a preop but the last guy told you that you were coming for surgery TODAY! And he said we just did cataract surgery here in the clinic? No, I know that he did not.

I have a feeling that especially with Ophthalmic conditions where laypeople are basically completely uninformed, they don't understand enough to give another doctor a summary of their medical record.

 

[Visionary]

Medicine as a business didn't become real to me until I was the one that had to cover my overhead, pay for my techs and employees wages and benefits, pay for the lease to my office and responsible for the purchase and maintenance of my equipment. It was further hammered home when I became responsible for covering my gigantic malpractice insurance premiums, and paying for my meetings, CME and license renewals. The "murkiness" you speak of often times boils down to "can I keep my doors open." I think the greed and laziness, which I can't deny does exist in some cases, is really the exception not the rule. Being in an academic center really skews your view because you deal with these handful of docs who seem to abuse the system. You don't get as easily exposed to the hundreds who do a great job for their patients.

To clarify a few points: I oftentimes give fortified antibiotics for free (we make them right in our office), they are expensive and we cover the loss for our uninsured patients. In cases of emergencies where I'm not on the patientes insurance plan, I will still hand out the antibiotics. Medicaid and unfunded patients are likely the MOST litigious of patients, don't fool yourself into thinking they are not. I have seen PLENTY of patients blame their doctor for something that was clearly not the physicians fault. Finally, not all doctors in private practice (as you imply) are the lazy, greedy, selfish, money hoarders that you believe. There are plenty of fantastic and ethical doctors that provide excellent care for all types of patients. The healthcare system is far more complex than you seem to understand and oftentimes hinders the ability of these fine physicians to practice in the way they would like.

Another difficulty in private practice can be the patient's ability to pay for surgery. I see any and all uninsured patients that are referred to me, regardless of ability to pay. I can lower their price and let them set up some type of payment plan for my fees (which very rarely ends up being paid), but I can't control the hospital or surgery center charges. They want money upfront no matter what, even for something emergent. If the patient truly can't come up with the money, they can't have surgery. In this rare instance, I've done a pneumatic in the office (for free) on a less than ideal candidate and it has worked, but your hands are kind of tied and I can see why someone would just not accept a patient or transfer care if there is a nearby academic center.

I have never been involved in a law suit, but I really don't think people are inclined to be litigious if you treat them with respect, take good care of them, and they feel like you honestly care.

I could go on and on about the Friday afternoon dumps I get in private practice from other ophthalmologists and optometrists. I think people tend to just dump in the path of least resistance. They call anything an RD and send it to you just to get it out of their office. Most of the time it isn't an RD, and often isn't even a retinal condition.

These are both spot on. I have never turned away a patient, but there are some things you simply can't get around as a small business owner, which is what we private practice docs are. There are means of funding treatments, if the patient can't afford them. Sometimes, you can just forego your own payment. For instance, I've performed lasers for free multiple times. The laser is paid for. There are no materials. It's just my surgeon's fee. If we're dealing with medications, I can eat the cost of an Avastin here and there, if the patient can't afford it. Problem is that a lot of the patients who need pharmacotherapy will need it repeatedly. You can only give away so much drug for free. The more expensive drugs can sometimes be covered by assistance programs, like Lucentis Access Solutions or Eylea 4 U. Not always, though. As MullerCell stated, you'll get nothing from hospitals. Even if you forego your own payment, it's minimal compared to the typical hospital expenses for a surgery. There are means of assistance in some cases, but those are easier to obtain in a university setting. That's why uninsured surgical cases usually get dumped on universities. It's not just "greedy" doctors. Bottom line, though, is that it's easy to be idealistic, while you're in training. In the real world, you have to run a business, and there's only so much charity work you can do before your margins start to hemorrhage. It's getting harder all the time with the addition of red tape and the decline of reimbursements.

 

[sheek111]

Still hard to predict, but there will always be a need for ophthalmologists. It's whether we work for ourselves in private practice vs being employed by "someone else".

I chose to be employed by the US Navy and moonlight in a private practice in Temecula (a practice I built with a few others from the ground up). Seeing the headaches of insurance reimbursements and declining reimbursements in private practice, I am so thankful I have a Navy job!

While moonlighting, for instance, the local ER doc calls me for a corneal foreign body removal at 2 AM. I asked for the patient's insurance info: the ER doc, says "it's a commercial insurance..." I spend an hour with the patient only to discover the patient's insurance is an HMO assigned to an IPA group (basically controlled by a primary care group). I am not hopeful of being paid for services rendered or my office manager spends a lot of time trying to get reimbursement (burning time, resources, and money); so, the cost of doing business is increasing while reimbursements are decreasing.

It's also harder to get reimbursements from some insurances due to "red tape", so we have accounts receivables that extend to nearly 6 months!!! Imagine doing a cataract surgery last September, and you're still waiting for reimbursement because of denial of claims and resubmissions! I don't mind charity work, but I need to pay the lease, loans, employees, malpractice insurance, and overhead. I am the last to be paid unfortunately, if there's anything left over.

Thank you for your insight, Dr. Doan. My mentor was actually referring to the EXACT same thing. He often talks about cost of running a business/private practice costs increasing, but reimbursements decreasing drastically. I think it's unfortunate, but according to him and other mentors, Ophtho likely will take a hit with impending ACA changes. He's also constantly talking about encroachment with Optoms, but that's a whole other story. Nonetheless, I still want to keep going and practice doing something I enjoy. But I do hope the future isn't as bleak as it seems. As for the private practice discussion, I think it's a sad realization, but I've also heard other residents speak similar sentiments about PP docs nearby. It probably does have a lot to do with incredibly crappy reimbursements/time lost seeing pts that can't pay etc., and of course the Friday afternoon punting. Either way, thank you guys for all of the insight! I hadn't checked this in weeks and was surprised to see the discussion it generated

 

[sheek111]

Also guys, just realized that the article I first cited doesn't show up unless you have a medscape account! Here's the cached version: http://webcache.googleusercontent.com/search?q=cache:2r_WbvNVpScJ:www.medscape.com/viewarticle/768302 &cd=1&hl=en&ct=clnk&gl=us

and studies to reduce tests ordered by Ophthalmologists during pre-op cataracts surgeries, which could further reduce reimbursements: http://webcache.googleusercontent.c.../viewarticle/843237+&cd=1&hl=en&ct=clnk&gl=us

 

[LightBox]

Thank you for your insight, Dr. Doan. My mentor was actually referring to the EXACT same thing. He often talks about cost of running a business/private practice costs increasing, but reimbursements decreasing drastically. I think it's unfortunate, but according to him and other mentors, Ophtho likely will take a hit with impending ACA changes. He's also constantly talking about encroachment with Optoms, but that's a whole other story. Nonetheless, I still want to keep going and practice doing something I enjoy. But I do hope the future isn't as bleak as it seems. As for the private practice discussion, I think it's a sad realization, but I've also heard other residents speak similar sentiments about PP docs nearby. It probably does have a lot to do with incredibly crappy reimbursements/time lost seeing pts that can't pay etc., and of course the Friday afternoon punting. Either way, thank you guys for all of the insight! I hadn't checked this in weeks and was surprised to see the discussion it generated

I think having a negative mindset will cause one to become a self-fulfilling prophesy. Yes obviously, everyone is concerned about declining reimbursements, but successful and entrepreneurial people will always find a way to adapt to the shifting sands of healthcare and business.

Btw, the overhead is more like 60-70% at most private practices, not 40-50%. But if your revenue is on the scale of 10 million, then a 30-40% profit ain't so bad. Look at any Fortune 500 company -- do you think their overhead is super low? Sure, you can have an overhead of 30%, but likely your revenue is like 700k. Which situation would you rather be in?!?

 

[MullerCell]

Overhead is kind of an interesting thing. Like stated above, I've heard of everywhere from 30%->80% in comp ophthalmology and different subspecialties in private practice. In some academic departments it's 90% or they even lose money. From my perspective, you shouldn't worry about it too much while you are still building your practice, unless it has been 5 years and you are still seeing 10-20 patients/day. Overhead will be a moving target based on how busy you are. If you aren't near full capacity, then it is going to be higher. Your marginal overhead keeps going down for each additional patient you see in a day. I think of it as, your first 10 patients of the day are to cover fixed costs and you make nothing, the next 10 have 75% overhead, then next 10 50%....and after about 50 patients it's mostly all gravy. You can see how a low volume provider could have a very high overhead and very high volume results in much lower overhead. Obviously, you can set your practice up to have overall lower vs. higher fixed costs depending on office size/#/location, # of staff, new/fancy equipment, ect. If you run a tight ship with few staff and a small office, then it will take fewer patients to profit, but you will likely be limited in the # of patients that you are capable of seeing in a day. If you don't have the referrals to build a higher volume practice, then it makes sense to run a smaller operation.

 

[sheek111]

Mullercell, thank you for that info. I didn't realize overhead was that variable btwn places. That's interesting. And lightbox, I apologize if I came across as having a negative mindset. I honestly just wanted to hear other perspectives after listening to what my mentor had to say about the future of Ophtho. I think as the economy goes down, business as a whole will fall by default. And ophtho being largely a private practice-based specialty, will suffer more than other specialties that have the benefit of working in hospitals. The declining reimbursements and fee for service changes will take their course, but I agree that people will find ways to get past that stuff. But I like Ophtho, and I'm still positive about it. I just wanted input

 

[sheek111]

I'm also still curious about the article from the New England Journal of Medicine this April though: http://webcache.googleusercontent.c.../viewarticle/843237 &cd=1&hl=en&ct=clnk&gl=us

There's a quote in it that's pretty strongly worded: "So I think given the waste and the harm, it's time for systems leaders to say: 'We're tracking you, and if you keep doing this, we're docking your ophthalmology payments for all of these extra things that you're doing.'"

Wanted to see what you guys thought about docking payments? Decreasing the number of pre-op visits/tests ordered for cataracts surgeries, based on evidence based medicine. The study didn't seem to have any major flaws. Assuming that this will make it harder to generate revenue from Ophtho surgeries soon, though....specifically cataract surgery. Thoughts?

 

[LightBox]

I'm also still curious about the article from the New England Journal of Medicine this April though: http://webcache.googleusercontent.c.../viewarticle/843237 &cd=1&hl=en&ct=clnk&gl=us

There's a quote in it that's pretty strongly worded: "So I think given the waste and the harm, it's time for systems leaders to say: 'We're tracking you, and if you keep doing this, we're docking your ophthalmology payments for all of these extra things that you're doing.'"

Wanted to see what you guys thought about docking payments? Decreasing the number of pre-op visits/tests ordered for cataracts surgeries, based on evidence based medicine. The study didn't seem to have any major flaws. Assuming that this will make it harder to generate revenue from Ophtho surgeries soon, though....specifically cataract surgery. Thoughts?

Okay, I spent the 2 minutes to read that article that you linked to. This article talks about pre-op medical clearance testing (e.g. blood work, EKG, etc) before cataract surgery. None of that stuff has anything to do with the reimbursements that us, Ophthalmologists, receive from cataract surgery. Unless of course you own the clinical lab...haha. All of those tests are ordered by the patient's PCP.

I tend to agree with this article that none of those things are really that necessary for a patient to undergo cataract surgery. I can count on my fingers the # of times a patient was not medically-cleared to undergo cataract surgery. They basically have to be having an active MI to not have this procedure. We make the PCPs lives easy by not requiring stopping of blood thinners, etc.

 

[sheek111]

Lol got it. Thanks! It seemed pretty anti-Ophthalmology from the way it was phrased, so I assumed they were talking about our pre-op tests as well.

 

[boanssi]

What do you guys think about the demand for ophthalmologists in the future?

 

[ophthope]

Aging population should provide plenty of demand for Ophthalmology. When you get old, your older eyes get problems. I don't think we've trained too many Ophthalmologists for there to be a problem with over-supply. Cannot say the same for our O.D. colleagues though, and I think that will have an impact on us as it is beginning to have on them as they flood the market with new grads.

 

[wowsa2291]

Wanted to write re: demand. There is DEFINITELY an oversupply of ODs flooding the market. Unfortunate, but they will certainly start to crowd the Ophtho market as well. A typical patient rarely knows the difference between the two with respect to levels of training. As OD grads increase, Ophthos will be forced to do nothing but surgery to generate income, as most of the normals get taken care of by ODs.
Here's an excerpt taken from AOA OD meeting in San Diego--
"Optometry’s scope of practice continues to broaden. The AOA is optimistic that state governments will continue to approve expansion of OD scope of practice in the future as the pressure mounts to contain growth in health care costs. Third party reimbursement accounts for a growing share of OD revenue. The Affordable Care Act is likely to precipitate further shifts in reimbursement for services received by ODs."

 

[wowsa2291]

About RVUs mentioned earlier in discussion. I'd highly recommend this for an accurate assessment of 2015 Ophthalmology reimbursement info:
http://consultqd.clevelandclinic.org/2015/01/ophthalmology-reimbursement-changes-coming-in-2015/
Vitrectomy RVU has decreased by as much as $417. Retina is being hit hard right now, as are others.

 

[wowsa2291]

I don't mean to bash Ophthalmology. Still has potential. But also don't think it's fair to sugar coat it for future grads. It's important to be aware of job outlook, income, so we can plan a realistic future. This discussion also could include the oversaturation of Ophtho (and ODs) in most, if not all desirable cities. These forums are probably hyped up, so read with caution. But you can refer to earlier threads if you're interested:
Read stuff by BitterWife on this thread. I don't know how true it is, but scary if real..
http://forums.studentdoctor.net/threads/patient-volume.728715/

http://forums.studentdoctor.net/threads/people-seem-so-disillusioned.860132/page-2
http://forums.studentdoctor.net/threads/job-market.736562/

 

[boanssi]

Do you think the demand for opthalmologists will increase in the coming decades, considering that chronic diseases such as hypertension and diabetes mellitus are getting increasingly detected at earlier stages and better treated?

In other words, from a demand standpoint, is ophthalmology a good specialty for a medical graduate?

 

[Trefoil]

Do you think the demand for opthalmologists will increase in the coming decades, considering that chronic diseases such as hypertension and diabetes mellitus are getting increasingly detected at earlier stages and better treated?

In other words, from a demand standpoint, is ophthalmology a good specialty for a medical graduate?

Honestly, hypertension and DM are very poorly controlled and treated in general. Truthfully, they are diseases of age and lifestyle. The population in western countries is getting older and fatter, so the prevelance and severity of these conditions is only increasing. Secondly, the bread and butter of ophthalmology actually revolves around cataracts, glaucoma, macular degeneration, DES, and acute eye issues. There is no way to prevent these conditions, so the prevalence will increase as the population ages. I would expect the demand for ophthalmology to increase in the next two decades. Pay is a more fickle thing based on Medicare and insurance models, but you will still have plenty of work if that is your question.

 

[MstaKing10]

the growing population of those entering their 60's and beyond as well as increased life expectancy figures will continue to feed the need for more ophthalmologists. Also consider emerging therapies and how that may increase the need for healthcare providers. 20 years ago a diabetic got scorched earth laser once and then followed up yearly. Now they get injections every 4 weeks. The sheer volume of patients that are returning on a regular basis has almost overwhelmed our practice and forced us to hire another ophthalmologist. Who knows what the next 20 years will bring.

 

[boanssi]

Thanks guys. That was exactly the answer I was searching for.

If anyone else would like to contribute to the discussion I'd appreciate it.

 

[Trefoil]

Thanks guys. That was exactly the answer I was searching for.

If anyone else would like to contribute to the discussion I'd appreciate it.

MstaKing brings up a great point. I think ophthalmology makes pretty large leaps from one decade to the next, and I imagine that the management of chronic disease like diabetic retinopathy, glaucoma, and macular degeneration will evolve quite a bit. Another area of interest that will see gains over the coming decades is the use of electrodes to return some degree of vision to the blind. The earliest gains have been in retinal implants for retinitis pigmentosa. These patients have intact retinal tissue that can be stimulated to trasmit information to the optic nerve. Once we can bypass the retina, these kinds of implants will have a much more widespread application. Similarly, if we could bypass the optic nerve entirely, devices that are implanted in or around the eye and sebsequently transmit information to the electrodes around the cortex through radio waves could also potentially restore some degree of vision in patients who have optic nerve damage. These types of devices are probably still a long way off, but these patients will need long term follow-up and will be an entirely new patient population. I think they will be somewhat similar in nature to the cochlear implant patient population that ENTs see.